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To apply for a month of free therapy from our friends at BetterHelp, please complete this form.
If you would like for your friend or family member to receive therapy, please send them this form or complete it with them.
Required Info
Would you be willing to tell us about your experience after your month is up?

Please note: this DOES NOT affect your chances of receiving therapy, it's just so we don't bug anyone who doesn't want us to bug them. *
Optional Info
Please note before completing the next section:

Everything below this point is optional. Completing it just tells us about who's participating, and this information will be anonymized before it's shared.
Whether you complete this section DOES NOT affect whether you will receive therapy.
Have you ever had therapy before?
For what reasons are you seeking therapy?
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